All Wales Policy for
Medicines Administration,
Recording, Review,
Storage and Disposal
November 2015
This report has been prepared by the Medicines Administration, Recording, Review,
Storage and Disposal (MARRS) Group, with support from the All Wales
Prescribing Advisory Group (AWPAG) and the All Wales Therapeutics and
Toxicology Centre (AWTTC), and has subsequently been endorsed by the All Wales
Medicines Strategy Group (AWMSG).
Please direct any queries to AWTTC:
All Wales Therapeutics and Toxicology Centre
University Hospital Llandough
Penlan Road
Llandough
Vale of Glamorgan
CF64 2XX
[email protected]
029 2071 6900
This document should be cited as:
All Wales Medicines Strategy Group. All Wales Policy for Medicines Administration,
Recording, Review, Storage and Disposal. November 2015.
All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal
CONTENTS
1.0 BACKGROUND...................................................................................................... 2
2.0 PURPOSE AND SCOPE ........................................................................................ 2
3.0 RESPONSIBILITIES OF HEALTH BOARDS AND NHS TRUSTS .......................... 2
4.0 MEDICINE ADMINISTRATION .............................................................................. 2
4.1 Authority to administer ........................................................................................ 2
4.2 Training .............................................................................................................. 2
4.3 Delayed or omitted administration ...................................................................... 3
4.4 Administration by healthcare employees............................................................. 3
4.5 Self-administration .............................................................................................. 3
5.0 RECORDING ......................................................................................................... 4
6.0 REVIEW ................................................................................................................. 4
7.0 STORAGE.............................................................................................................. 4
7.1 Responsibilities................................................................................................... 4
7.2 Storage areas ..................................................................................................... 5
8.0 DISPOSAL ............................................................................................................. 5
REFERENCES ............................................................................................................. 6
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All Wales Medicines Strategy Group
1.0 BACKGROUND
The All Wales Policy for Medicines Administration, Recording, Review, Storage and
Disposal (MARRS) has been developed as a response to medicines practice issues
identified as part of the Trusted to Care report, published in 20141. It provides a
standards framework for health boards and trusts in Wales, which must be
implemented through local procedures.
2.0 PURPOSE AND SCOPE
The purpose of the policy is to set out the minimum standards of practice that must be
adopted by all healthcare employees involved in the administration, recording, review,
storage and disposal of medicines in Welsh hospitals. The implementation of these
standards will ensure that medicines administration and practices are of a consistently
high standard and that patients, staff and visitors to Welsh hospitals are protected from
the harmful effects of medicines through robust medicines storage practices.
3.0 RESPONSIBILITIES OF HEALTH BOARDS AND NHS TRUSTS
Each health board and trust must ensure that:
• There is a formal process for the approval and review of procedures pertaining
to MARRS matters. Only documentation approved for use by the health board
or trust through this formal process may be used by healthcare employees.
• All healthcare employees involved in the administration of medicines have
received appropriate education, have been assessed as competent and work
within the limitations of their competence2. This competence will be re-assessed
as part of the annual appraisal process.
• Policies and procedures that clearly indicate to healthcare employees which
medicines-related incidents are reportable are in place. These policies and
procedures must be supported by training on the use of local reporting systems.
Systems must also be developed to improve the quantity and quality of incident
reports relating to medicines, and the subsequent investigation of these errors,
by addressing the known barriers to reporting and effective investigation.
• A professional duty of openness and honesty is promoted and staff are
supported to raise concerns that may impact on patient or public safety and to
take the necessary action to address these concerns where appropriate.
4.0 MEDICINE ADMINISTRATION
The administration of medicinal products must be informed by guidance from
appropriate regulatory boards and professional bodies3–5.
4.1 Authority to administer
Health boards and trusts must have local procedures in place that identify acceptable
authorities against which a healthcare employee can administer medicines.
4.2 Training
All staff involved in medicines administration must receive medicines management
education/training as part of their induction to the health board or trust, and update their
knowledge of MARRS practices every three years by completing the All Wales MARRS
education programme. A practitioner’s medicines practice must also form part of the
individual’s annual review process, giving both the reviewer and practitioner opportunity
to identify any learning needs and actions required in the intervening years, between
undertaking the required learning programme every third year.
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All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal
4.3 Delayed or omitted administration
Health boards and trusts must have formal procedures in place for healthcare
employees to follow when medicines administration is either delayed or omitted i.e. in
the following circumstances:
a) a patient is unable to take a medication (where a medication is prescribed for
administration via the oral route but the patient is ‘nil by mouth’ or where a
medication is prescribed to be administered by the intravenous (IV) route but
there is no cannula in place);
b) a patient refuses to take a medicine;
c) a medication is unavailable when it is due to be administered.
4.4 Administration by healthcare employees
Only healthcare employees who have been assessed as competent can administer
medicinal products. Once assessed as competent, the healthcare employee can,
where deemed appropriate, administer medicines without involving a second person.
However, the administration of certain medicines and/or the administration of
medicines to certain groups of patients will require a second-check. It is the
responsibility of the health board or trust to identify when and where a second check is
required. Two registered healthcare professionals may be required for both the
checking and the administration of medicines in the following situations:
• when the medicinal product is a high risk medicine administered via the IV or
subcutaneous (SC) route;
• when the medicinal product is a controlled drug;
• when the medicinal product is a cytotoxic agent;
• where the recipient of the medicinal product is a child, young person or
neonate;
• when calculation of dosage is required (including dose adjustments for infusions
already in progress);
• when an IV administration is made up or an IV or SC infusion is commenced or
the rate of infusion is changed.
For any two-person procedure, both healthcare professionals are required to
independently check the medicine and its administration. Both signatures are required
on the prescription chart and any associated documentation. Healthcare professionals
undertaking IV administration of injections and fluids are required to undergo additional
training and must be deemed competent before undertaking this aspect of medicine
administration.
4.5 Self-administration
If a patient wishes to self-administer their medicine whilst in hospital, they should be
supported to do so where possible. Health boards or trusts must have procedures to
facilitate the self-administration of medicines by a patient. The procedure must include
guidance for assessing the ability of a patient to self-medicate. This assessment must
be undertaken by a suitably trained healthcare professional, and be documented in the
patient notes and retained in the patient file.
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All Wales Medicines Strategy Group
5.0 RECORDING
A clear, accurate and immediate record of all medicines administered must be made by
the healthcare employee responsible for administration. Medicines scheduled to be
taken by the patient but which are not taken (e.g. due to a lack of availability or refusal
by the patient) must also be recorded. In order to account for the administration, the
healthcare employee must observe the patient taking the medicine before recording
their signature. If the medicine or fluid is given as an intermittent or continuous infusion,
the administration chart should be signed immediately after the infusion has
commenced. In the event of an emergency (e.g. cardiac arrest), a list of medicines
administered to the patient must be documented and a copy held within the patient’s
notes in accordance with local procedures.
6.0 REVIEW
The health board or trust must ensure processes are in place for appropriate and timely
review of a patient’s medicines regime.
It is the responsibility of the person administering a medicine to contact the prescriber
of the medicine or another authorised prescriber without delay where:
• contraindications to the prescribed medicine are discovered;
• the patient develops a reaction to the medicine;
• assessment of the patient indicates that the medicine is no longer suitable; or
• the medicine has been omitted.
Prescribers have a responsibility to ensure that the medicines they have prescribed
have been administered. The healthcare professional caring for patients deemed
suitable for self-administration has continuing responsibility for their daily assessment,
to ensure the practice remains safe.
7.0 STORAGE
7.1 Responsibilities
Health boards or trusts must ensure medicines are stored in accordance with current
legislation and national guidance6. The service director/lead for pharmacy and
medicines management is responsible for establishing a system for the security of
medicines in consultation with appropriate medical and senior nursing staff. The sister,
charge nurse or clinical lead of the ward or unit is responsible for the secure storage of
medicines in their area. The sister or charge nurse may delegate some duties involved
in the storage of medicines but cannot delegate responsibility. The Nursing and
Midwifery Council Code dictates that a registrant takes all steps to ensure medicines
are stored securely7.
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All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal
7.2 Storage areas
There must be separate lockable ward cupboards, fridges and, where required,
freezers for:
• controlled drugs – a controlled drugs cabinet (that complies with the Misuse of
Drugs [Safe Custody] Regulations 19738)
• oral medicines – cupboard
• topical medicines – cupboard
• medicines that require storage in a fridge or freezer
• epidural infusions (where permitted) – cupboard
Suitable storage areas must also be provided for the following:
• diagnostic reagents, including urine testing
• intravenous fluids and sterile topical fluids
• flammable preparations
• dressings
Cupboards to be used for oral and topical medicines should comply with current
specifications. Where computer-controlled cabinets are used for medicines, they
should provide at least the same level of security as traditional lockable cupboards.
Medicine trolleys, where used, should be lockable and immobilised when not in use.
Treatment room doors should be locked when not in use, with access restricted to
designated staff. Healthcare support workers may be permitted to put away delivery of
stock medicines in general medicines cupboards. They must carefully check the
picking list and make the nurse in charge aware of any discrepancies.
When schemes for self-administration of medicines and/or “one-stop” dispensing are in
operation, each patient involved in the scheme should have a lockable area for
medicines (e.g. drawer, individual cupboard). Only a registered healthcare professional
can place medicines into the patient’s bedside medicine storage cupboard.
For clinical emergencies, e.g. cardiac arrest, wards and departments must have a
source of urgent medical products. The content must be agreed by the Resuscitation
Committee. These contents should be held in boxes clearly marked “for emergency
use”. These boxes should be tamper evident and should not be held in a locked
cupboard, but at strategic and accessible sites.
8.0 DISPOSAL
It is a legal requirement that all waste is disposed of correctly. Medicines are
categorised as clinical waste for waste management/segregation purposes. All
medication must be disposed of safely in accordance with the Hazardous Waste
Regulations (2005)9. Controlled drugs must be destroyed in such a way that the
medicine is denatured or rendered irretrievable so that it cannot be reconstituted or
reused. Where denaturing is carried out on the wards, the methods used must be those
currently recommended by the Royal Pharmaceutical Society10.
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All Wales Medicines Strategy Group
REFERENCES
1 Dementia Services Development Centre, The People Organisation. Trusted to
Care. Sep 2014. Available at:
http://gov.wales/topics/health/publications/health/reports/care/?lang=en.
Accessed Jul 2015.
2 Health and Care Professions Council. Standards of Conduct, Performance and
Ethics. 2012. Available at: http://www.hpcuk.org/aboutregistration/standards/standardsofconductperformanceandethics/.
Accessed Jul 2015.
3 General Medical Council. Good Practice in Prescribing and Managing Medicines
and Devices. 2013. Available at: http://www.gmcuk.org/guidance/ethical_guidance/14316.asp. Accessed Jul 2015.
4 NHS. Promoting Safer Use of Injectable Medicines. Mar 2007. Available at:
http://www.nrls.npsa.nhs.uk/resources/?entryid45=59812. Accessed Jul 2015.
5 Nursing and Midwifery Council. Standards for Medicines Management. Apr 2010.
Available at: http://www.nmc.org.uk/standards/additional-standards/standards-formedicines-management/. Accessed Jul 2015.
6 Royal Pharmaceutical Society of Great Britain. The Safe and Secure Handling of
Medicines: A Team Approach. Mar 2005. Available at:
http://www.rpharms.com/support-pdfs/safsechandmeds.pdf? Accessed Jul 2015.
7 Nursing and Midwifery Council. The Code. Professional Standards of Practice
and Behaviour for Nurses and Midwives. Jan 2015. Available at:
http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revisednew-nmc-code.pdf. Accessed Jul 2015.
8 UK Government. The Misuse of Drugs (Safe Custody) Regulations 1973. 1973.
Available at: http://www.legislation.gov.uk/uksi/1973/798/body/made. Accessed
Jul 2015.
9 UK Government. The Hazardous Waste (England and Wales) Regulations 2005
(amended 2009). 2009. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/218
704/haz-waste-regs-guide.pdf. Accessed Jul 2015.
10 Royal Pharmaceutical Society. Guidance for Pharmacists on the Safe Destruction
of Controlled Drugs England, Scotland and Wales. 2007. Available at:
http://filesdown.esecure.co.uk/NorthLancsPCT/Guidance_20for_20Pharmacists_
20on_20the_20safe_20destruction_20of_20Controlled_20Drugs_20Appendix_20
4.pdf_09032009-1615-16.pdf. Accessed Jul 2015.
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